Attachment Of Posterior Cruciate Ligament Research Articles

Arthroscopic Suture Fixation for Avulsion Fractures in the Tibial Attachment of the Posterior Cruciate Ligament

The purpose of the study was to highlight our surgical technique of arthroscopic suture fixation for acute tibial eminence posterior cruciate ligament (PCL) avulsion fractures, clinical and radiographic outcomes, and complication rates. This prospective study enrolled patients who had undergone arthroscopic reduction and suture fixation by use of 4 No. 5 Ethibond sutures (Ethicon, Somerville, NJ) for image-proven displaced PCL attachment fractures of the tibial eminence with posterior knee instability of grade II or higher. The mean follow-up period was 36 months (range, 24 to 45 months). Follow-up assessment included 3 different functional scores, KT-1000 arthrometry (MEDmetric, San Diego, CA), and radiographic evaluation. The mean preoperative Lysholm score in the 36 patients was 35 (range, 26 to 55); the mean postoperative Lysholm score was 95 (range, 80 to 100). The mean preinjury and preoperative Tegner scores in the 36 patients were 7.4 ± 1.6 (range, 5 to 9) and 3.2 ± 1.5 (range, 2 to 5), respectively. The mean postoperative Tegner score was 7.0 ± 1.8 (range, 5 to 9). At the final follow-up, the International Knee Documentation Committee scores were observed to be normal (grade A) or nearly normal (grade B) in 33 patients (91.7%) and abnormal (grade C) in 3 patients (8.3%). All 36 fractures achieved union within 3 months. No significant complications such as arthrofibrosis, loss of initial fixation, or wound infection were noted. Treatment of tibial PCL avulsion fractures by arthroscopic suture fixation is a successful technique to restore tibial avulsion injuries of the PCL with well-documented radiographic healing, good clinical outcomes, and low complication rates. Level IV, therapeutic case series.

How much of the PCL is really preserved during the tibial cut?

There are two different techniques for retaining the posterior cruciate ligament (PCL) in total knee arthroplasty. The attachment of the PCL can be spared during resection of the tibial plateau, so that a small posterior bone block remains. In contrast to this, many surgeons resect the tibial plateau completely and detach a part of the tibial PCL attachment from the resected material. The objective of this study was to determine how big this part is in an anatomical resection of the tibial plateau with 0° and 7° slope and whether it is gender-dependent. Two hundred consecutive patients who had undergone MRI of a knee joint were included. Patients were excluded if they were younger than 18 years or had dysplasia of the knee joint or injuries of the posterior cruciate ligament. The MRIs of 182 knees that fulfilled the inclusion criteria were analysed. For each knee, an anatomical tibial resection with 0° and 7° posterior slope was simulated, and the parts of the tibial PCL attachment that were resected and retained were determined. Given a measured tibial resection with 0° slope, 45 ± 28% of the tibial PCL attachment was removed in the men, compared with 46 ± 30% in the women (n.s.). Given a resection with 7° slope, 69 ± 24% of the tibial PCL attachment was removed in the men and 67 ± 25% in the women. This corresponded to a complete resection in 19 men (20%) and 16 women (24%). Independently of gender, the anatomical resection of the tibia leads to the removal of a considerable part of the tibial PCL attachment, if this is not spared in the form of a bone block during resection. This becomes increasingly relevant with higher posterior slope of the resection plane. In the case of a cruciate-retaining surgical technique, the retention of the posterior tibial cortical bone in the area of attachment of the PCL is therefore strongly recommended. II.

Computed tomography evaluation of the femoral and tibial attachments of the posterior cruciate ligament in vitro

The optimal technique for reconstruction of the posterior cruciate ligament (PCL) is controversial. Regardless of surgical technique and graft choice, anatomic graft placement is essential for successful outcome. The purpose of this study is to evaluate the size and location of the insertions of the PCL using a computed tomography (CT) protocol. The insertions in ten knees were marked in vitro with plastic markers. The CT examination was performed with the knee in extension. On the femur, the position of the center of the insertion site was evaluated relative to Blumensaat's line and the anterior articular surface. On the tibia, the location of the center of the insertion site was described relative to the borders of the tibial plateau and the retrospinal surface. The surface area of the femoral insertion measured 232mm(-2) and was centered 8.9mm from the roof of the intercondylar notch and 18.7mm from the anterior articular cartilage surface. The surface area of the tibial insertion was 155mm(2) and was centered 9.1mm from the posterior border of the tibia on the retrospinal surface, 1.6mm inferior to the plane of the tibial articular surface. This point was on average 49% of the way across the plateau relative to the medial edge of the plateau and 87% of the way across the plateau relative to the anterior edge. Computed tomography can provide detailed localization of the PCL attachment sites on the femur and tibia. Radiation exposure and cost may preclude routine use.

Refixation of Tibial Bony Avulsions of the Posterior Cruciate Ligament with a Hook Plate

Posteromedial approach to the knee. Exact reduction and fixation of avulsed tibial attachment of posterior cruciate ligament with small-fragment plate. Avulsed tibial attachment of posterior cruciate ligament. Ligamentous rupture of the posterior cruciate ligament. Local soft-tissue problems. Posteromedial approach with mobilization and retraction of the medial gastrocnemius muscle. Subperiosteal detachment of the popliteal muscle. Identification of fracture site. Longitudinal incision of the posterior capsule of the knee. Debridement of the fracture site, reposition and stabilization with small-fragment plate. Partial weight bearing with 15 kg for 6 weeks, limitation of knee flexion to 90° for 6 weeks. A special joint orthesis is not necessary. The use of an EMT unit is recommended to prevent muscular atrophy. Six patients (four female, two male) with avulsed tibial attachment of posterior cruciate ligament were treated using the posteromedial approach.

Review: femoral tunnel placement for PCL reconstruction in relation to the PCL fibre bundle attachments

Accurate placement of the femoral tunnel position is an important aspect of cruciate ligament reconstruction surgery. However, a wide range of positions have been described in the literature for the femoral tunnels for posterior cruciate ligament (PCL) reconstruction, and there is no consensus regarding the optimal placement. It was hypothesised that some of the prior studies used femoral PCL graft tunnels that were outside of the anatomical attachments. A systematic review and descriptive anatomical study in vitro were undertaken. Fifty articles that described PCL reconstruction since 1917 were reviewed; the description of the femoral tunnel placement was reproducible from only 20 of these. A right, distal femur was disarticulated and the PCL attachment was dissected; the centres of the anterolateral and posteromedial bundles were marked and confirmed to be close to the mean published data. The tunnel positions described in the 20 papers were also marked. The descriptions of 15 of the 20 anterolateral and 4 of the 5 posteromedial bundle tunnel centres were close (within +/-2 mm deep and +/-01:00 o'clock) to the anatomical centres of the bundle attachments. Other tunnels were placed either deeper or shallower than the anatomical attachments. The mean positions were: 7 mm from the articular cartilage at 1 o'clock for the anterolateral bundle, and 8 mm from the cartilage at 3 o'clock for the posteromedial bundle, in a right knee. It was concluded that it was not possible to replicate the tunnel positions used in most of the literature because of inadequate descriptions. Most of the usable descriptions of the anterolateral bundle position were close to the anatomical centre, but some tunnels were placed non-anatomically. A reproducible system for description of the femoral tunnel positions should be used.

The clinical anatomical research of the tibial attachment of the posterior cruciate ligament and the tibial tunnel position in double-bundle posterior cruciate ligament reconstruction

To provide the data on the shape, sizes, and locations of the attachments of the anterolateral bundle (ALB) and posteromedial bundle (PMB) of the posterior cruciate ligament (PCL) to the tibia, and to determine the reference landmarks and the methods for tibial tunnel positioning in double-bundle PCL reconstruction using double-double tunnel. Thirty cadaveric knees were used as specimens. PCLs were separated into bundles according to the PCL tension pattern during knee flexion-extension, and the functional bundle in each bundle was determined. Data were obtained to describe the size, shape, position, and center of the attachments of PCL bundles. The reference landmarks and methods for tibial tunnels positioning in double-bundle PCL reconstruction using double-double tunnel were determined. The PCL insertion site was situated in the posterior intercondylar fossa. The longitudinal axis of the tibial attachment of PCL proceeded from proximal medial to distal lateral, and the mean angle between them and the tibial shaft was (16.5 +/- 1.4) degrees . The tibial insertion site of ALB and PMB were arranged in the proximal and distal on the whole, the tibial attachment of ALB could generally be described as rhomb in shape, and the mean area of it was (90 +/- 20) mm(2); the tibial attachment of PMB was rectangle in shape, the mean area of it was (96 +/- 32) mm(2), there was no statistic difference between the area of them (P > 0.05). There were functional bundles in both ALB and PMB persistently, which attached to the distal-lateral portion of the tibial attachment of ALB and the distal-medial portion of the tibial attachment of PMB respectively, they were both oval in shape, the mean area of them were (35 +/- 12) mm(2) and (36 +/- 6) mm(2) respectively, the difference between them was no statistic significant (P > 0.05). The mean distance between the centres of the tibial attachments of the functional bundles of ALB and that of PMB was (12.7 +/- 1.9) mm. The medial tibial spine, lateral tibial spine and the bony ridge on the posterior-proximal tibia were the key anatomic landmarks that could be used to aid in placement of independent tibial tunnels for a 2-bundle PCL reconstruction. The tibial attachment of the PCL is sufficiently large to allow for placement of 2 independent tunnels. There are functional bundles in both ALB and PMB persistently and the optimum position for the tibial tunnel in double-bundle PCL reconstruction using double-double tunnel should be located in the attachment sites of the functional bundles of ALB and PMB.

The Lateral Intercondylar Ridge—A Key to Anatomic Anterior Cruciate Ligament Reconstruction

As our techniques for anterior cruciate ligament reconstruction have evolved, our focus has drifted from anatomy. We believe that it is important to hearken back to anatomy and to fully understand normal anatomy so that we can try to restore it with anterior cruciate ligament reconstruction surgery. The results associated with current anterior cruciate ligament reconstruction techniques are adequate but not exceptional. A recent meta-analysis of the outcomes of anterior cruciate ligament reconstruction indicated that only 33% of patients who had reconstruction with hamstring tendon graft and 41% of those who had reconstruction with bone-patellar tendon-bone graft had normal outcomes according to the final International Knee Documentation Committee score1. There is clearly room for improvement, and we think that the keys to improvement will be based on anatomical anterior cruciate ligament reconstruction. In their paper entitled “Morphology of the Femoral Intercondylar Notch,” Farrow et al. evaluate the anatomy of the lateral intercondylar notch in 200 cadaveric specimens. The authors' goal—namely, to perform a detailed study of the area where the anterior cruciate ligament attaches in order to provide more reliable guidance for femoral tunnel placement—is admirable. The authors note that the osseous ridge that Dr. Clancy termed the “resident's ridge” was present in 194 of …

The Lateral Intercondylar Ridge-A Key to Anatomic Anterior Cruciate Ligament Reconstruction

The Lateral Intercondylar Ridge-A Key to Anatomic Anterior Cruciate Ligament Reconstruction

Function of Posterior Cruciate Ligament Bundles during in Vivo Knee Flexion

Background The biomechanical functions of the anterolateral and posteromedial bundles of the posterior cruciate ligament over the range of flexion of the knee joint remain unclear. Hypothesis The posterior cruciate ligament bundles have minimal length at low flexion angles and maximal length at high flexion angles. Study Design Descriptive laboratory study. Methods Seven knees from normal, healthy subjects were scanned with magnetic resonance, and 3-dimensional models of the femur, tibia, and posterior cruciate ligament attachment sites were created. The lines connecting the centroids of the corresponding bundle attachment sites on the femur and tibia represented the anterolateral and posteromedial bundles of the posterior cruciate ligament. Each knee was imaged during weightbearing flexion (from 0° to maximal flexion) using a dual-orthogonal fluoroscopic system. The length, elevation, deviation, and twist of the posterior cruciate ligament bundles were measured as a function of flexion. Results The lengths of the anterolateral and posteromedial bundles increased with flexion from 0° to 120° and decreased beyond 120° of flexion. The posteromedial bundle had a lower elevation angle than the anterolateral bundle beyond 60° of flexion. The anterolateral bundle had a larger deviation angle than the posteromedial bundle beyond 75° of flexion. The femoral attachment of the posterior cruciate ligament twisted externally with increasing flexion and reached a maximum of 86.4° ± 14.7° at 135° of flexion (P < .05). Conclusion These data suggest that there is no reciprocal function of the bundles with flexion, which is contrary to previous findings. The orientation of the anterolateral and posteromedial bundles suggests that at high flexion, the anterolateral bundle might play an important role in constraining the mediolateral translation, whereas the posteromedial bundle might play an important role in constraining the anteroposterior translation of the tibia. Clinical Relevance These data provide a better understanding of the biomechanical function of the posterior cruciate ligament bundles and may help to improve the design of the 2-bundle reconstruction techniques of the ruptured posterior cruciate ligament.

The Attachments of the Fiber Bundles of the Posterior Cruciate Ligament: An Anatomic Study

This study aimed to provide data on the sizes and locations of the attachments of the posterior cruciate ligament (PCL) to the tibia and the femur. We studied 39 cadaveric knees. The PCL consistently separated into anterolateral (AL) and posteromedial (PM) fiber bundles. Data were obtained to describe the size, position, and center of the PCL bundles related to clock positions and referenced to the center of the circular posterior medial condyle on the femur, as well as to the mediolateral and anteroposterior dimensions of the tibia. The coordinates for the femoral attachment of the PCL bundles were measured parallel to the femoral shaft and to the femoral intercondylar notch roof. A wide variation in shape and size of the PCL attachment was found on the femur, but the pattern of attachment to the tibia was consistent. The tibial attachment of the PCL occupied the posterior intercondylar fossa. The AL bundle's anterior limit was the root of the posterior horn of the medial meniscus, and the PM bundle extended below the joint line by 7 +/- 2 mm (mean +/- SD). On the femur, the AL bundle was centered at 7 +/- 2 mm from the articular cartilage at 10:20 +/- 00:30 o'clock, and the PM bundle was centered at 10 +/- 3 mm from the cartilage at 08:30 +/- 00:30 o'clock. The PCL extended from beyond the 12-o'clock position in all specimens. Accurate knowledge of the anatomic positions of the bundles of the PCL on both femur and tibia is essential to developing more successful reconstruction techniques. The results of this study may be applied to the design of guidance systems for double-bundle PCL reconstruction techniques and as a reference for graft tunnel placement in in vitro or clinical follow-up studies.

Arthroscopic Reconstruction of the Posterior Cruciate Ligament Using Tibial-Inlay and Double-Bundle Technique

Biomechanical research has suggested that the double-bundle and tibial inlay technique is superior to the single-bundle and the transtibial tunnel method for posterior cruciate ligament (PCL) reconstruction. A combination the posterior tibial inlay and femoral double-bundle technique is thought to be an ideal method for PCL reconstruction. Recently, we successfully performed arthroscopic PCL reconstruction using the tibial-inlay and double-bundle technique. Achilles tendon–bone allograft is used and the bone plug for the arthroscopic tibial inlay fixation is designed in a cylindrical shape and perpendicular to the fiber texture of the Achilles tendon. Achilles tendon is manually split into deep and superficial layers to reconstruct anterolateral and posteromedial bundles as the natural insertion of PCL. The intra-articular lengths of each bundle between tibial tunnel and 2 femoral tunnels are measured to achieve fixation of the graft to the original PCL attachment. After tibial bone plug fixation with an absorbable interference screw and additional suture anchoring, the anterolateral bundle is fixed in a reduction position with the knee in 90° of flexion and the posteromedial bundle is fixed nearly in extension. This procedure makes it possible not only to reproduce the original concept of PCL tibial inlay graft arthroscopically without posterior arthrotomy, but also to achieve a more anatomic PCL reconstruction of the 2 bundles.

Identification of the optimal intercondylar starting point for retrograde femoral nailing: an anatomic study.

Retrograde nailing of femoral shaft fractures is an effective and increasingly more popular method of fracture fixation. However, concern remains regarding the effect of the intercondylar entry-portal location on knee function. The optimal entry-portal location was identified in cadaver femurs. Approximating the clinical intraoperative situation, a threaded guidewire was inserted into each of 26 distal femur specimens and positioned in the center of the femoral shaft as determined by anteroposterior and lateral fluoroscopic imaging. Each guidewire was then overdrilled with a 12-mm cannulated drill bit. All entry-portal locations were recorded relative to the posterior cruciate ligament attachment and the intercondylar groove and mapped relative to the known patellofemoral contact area. The starting holes averaged 6.21 mm anterior to the posterior cruciate ligament attachment and 2.67 mm medial to the intercondylar groove. Overall, 100% of starting portals were located in safe areas relative to the patellofemoral contact area. In the vast majority of femurs, the optimal entry portal for retrograde femoral nailing (in line with the long axis of the femur) is located in the expected safe position, anterior to the posterior cruciate ligament insertion and slightly medial to center of the intercondylar groove. However, because of anatomic variability, the ideal starting position occasionally may be located in a patellofemoral contact area. Potential compromise of the patellofemoral contact area by the retrograde nail entry portal can and should be recognized before nailing, allowing the surgeon the option of altering the surgical technique.

Posterior trans-septal portal for arthroscopic surgery of the knee joint

Summary: The authors introduce a safe arthroscopic technique of making a portal through the posterior septum of the knee joint, posterior to the posterior cruciate ligament (PCL). This posterior trans-septal portal makes it possible for the arthroscope or the working instruments inserted through the posteromedial portal to reach the posterolateral compartment. With this portal, complete arthroscopic visualization of the posterior compartment and easier arthroscopic procedures for the posterior compartment of the knee joints are possible, including the posterior and posterosuperior aspect of the both femoral condyles, the posterior horns of both menisci, the posterior and inferior portion of the PCL, the posterior meniscofemoral ligament, the posterior septum, and the posterior capsule. We have used this technique in more than 150 knees for arthroscopic total synovectomy for arthritis of various origins, arthroscopic PCL reconstructions, arthroscopic removal of encapsulated loose bodies or tumors located behind the PCL, arthroscopic repairs of tears in the posterior horns of the medial menisci using the all-inside technique, arthroscopic pullout suture fixation of the avulsion fracture of tibial attachment of PCL, and others. No complications such as injuries of the popliteal neurovascular structures have occurred in our experience.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 7 (October), 2000: pp 774–779

Posterior cruciate ligament (PCL) reconstruction--an in vitro study of isometry. Part I. Tests using a string linkage model.

In six intact cadaver knees, we measured how the distance between six selected points in and around the femoral and tibial attachment area of the posterior cruciate ligament (PCL) changed with knee flexion. After complete removal of the PCL, 2-mm drill holes were made at the selected points. Each femoral point was measured against each tibial point using a heavy string that was passed through the drill holes. The distal end of the string was attached to a measuring unit. The changes in femorotibial distance were noted during flexion from 0 degrees to 110 degrees in 10 degree steps. The tibial drill hole locations had only a minor effect on the changes in femorotibial distance. The most isometric point was located in the centre of the posterior intercondylar area. The femoral locations of the drill holes were the primary determinant of whether the distance increased, decreased or remained nearly constant. According to our results, the most isometric femoral point is located at the posterosuperior margin of the anatomical PCL attachment. Using the tibial isometric point as a reference, the femoral points positioned anterior or posterior to the isometric point produced considerable changes in the femorotibial distance upon knee flexion. The anterior point led to an increase of about 7-8 mm at 110 degrees of flexion, the posterior point to a decrease of the same extent. Much smaller changes in femorotibial distance resulted from the points located superior or inferior to the femoral isometric point.(ABSTRACT TRUNCATED AT 250 WORDS)

Femoral anteversion: assessment based on function axes.

This study describes a clinically oriented anatomical assessment of anteversion on 32 cadavers ranging from 61 to 89 years. The method used a three-dimensional reference system based on functional axes of the femur. Each soft tissue-free femur was mounted on an osteometric table and aligned to its functional axes. The long axes were defined as passing from the centre of the femoral head to the femoral attachment of the posterior cruciate ligament (PCL). A line that ran through the PCL attachment (equal distal origin of this system) and was parallel to a transepicondylar line served as transverse axis. Anteversion of the femur was defined as an angle formed to the transverse axis by a line running through the centre of the femoral head through the midpoint of the narrowest segment of the femoral neck. The measurement mean for anteversion among these specimens was 7.4 degrees with a range from -10.8 degrees (retroversion) to 22.1 degrees. There was no statistical difference in mean values (p less than 0.05) between sexes or between right and left sides of the group; however, there were large variations for anteversions when each side in the same individual was compared (although there was no dominant side). Retroversions were observed in four of 32 femurs (12.5%). No correlation was found between the anteversion in these femurs and rotational geometry at the knee. We compared our data with those obtained by conventional techniques, by which anteversion for each femur was measured after the bone had been placed on a flat surface.(ABSTRACT TRUNCATED AT 250 WORDS)